Nudge or push? Voluntary vs legislative approaches to public health

Changing people’s behaviour is complex, and at the root of many health issues. Should they be gently nudged to make healthier choices or have those choices effectively made for them? It’s a question that often confronts those of us working in health.

People’s behaviour is already influenced by their existing social, economic and physical circumstances, and policies that address these can help tip the balance from an obesogenic environment towards one that makes it easier to make healthier choices. After all, it’s clear that pricing and availability influence consumer behaviour – something industry has recognised and exploited for decades.

So the question is, do we adopt voluntary or legislative approaches?

Certainly the voluntary approach seems to be the way things are headed. At a McCabe Centre workshop in Montreal in August on the law and cancer control I took part in an interesting discussion on the law in cancer prevention (around tobacco, alcohol, obesity and solaria).

There were over 40 people from around the world, with different interests and expertise in the law, cancer and public health. The chair asked if anyone knew of a successful voluntary approach that had been rigorously independently evaluated and had a demonstrable impact on public health. No one did – though of course that doesn’t mean examples don’t exist.

In principle it should be possible to achieve meaningful results with voluntary approaches if there is strong government leadership and industry cooperation. But in practice what seems more common is weak or uninspired leadership, unambitious targets and insufficiently stringent pledges, criticisms that have been leveled at both the Responsibility Deal in the UK and the European Platform for Action on Diet, Physical Activity and Health.

Such schemes may act as a smokescreen, giving the impression that something important is happening while delaying or pre-empting more effective government-led regulation. Their voluntary nature means that coverage is not comprehensive across all companies and markets. Commitments are not guaranteed and they can be reversed at any time.

But legislative approaches are not without problems either. Market-based measures can be motivated by public health goals, for instance to change consumption of certain types of foods. But they may also be financially motivated – raising revenue for government as well as potentially reducing health care costs, or both. If it works, why not? But planning what will work requires careful thought and the impact needs evaluation. Sometimes well-intentioned policies can have unplanned effects.

The Danish government recently scrapped the world’s first “fat tax” saying that it inflated food prices and put Danish jobs at risk. Since it was only in place a year and hasn’t been evaluated its impact on public health is unknown. But this is a problem that won’t go away. Just last week the Labour Party in the UK called for a ban on high-sugar cereals to tackle childhood obesity. Currently the Government is focused on reducing the levels of fat, sugar and salt in foods via the Responsibility Deal.

At WCRF International we believe that to help avoid unplanned and possibly unhelpful effects it’s better to take account of the overall composition of foods and diets, rather than just one component. This avoids the potential pitfalls of a single nutrient tax and can encourage producers and retailers to consider product reformulation, which could have a more significant health impact than a singly targeted fat tax, for example.

Of course voluntary and legislative approaches are not mutually exclusive. One may lead to the other or they can exist in parallel. What’s important is that they are rational, rigorous and properly evaluated.

If you know of schemes that tick these boxes, do get in touch. We’d like to know.

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